How much autonomy do midwives have in the NHS?

How much autonomy do midwives working in the NHS have?

How much autonomy do those of you working in the NHS feel you actually have? For example, if you have a woman in labour, on the delivery suite – would you expect a senior midwife or doctor to come in without your asking for help to give advice? Would you have to act on that advice? Even if it overruled the woman’s wishes? If there are labour ward guidelines, do you have a choice as to whether you abide by them? Antenatally, how many of you are `lead professionals’ – do `normal’ women have obstetric appointments?

I’m looking for a new job, and wondering what to expect elsewhere – please help me out here!
Sara

Contrasting Practice

When I worked in London as part of a midwifery practice group, I did feel that I had quite a good deal of autonomy, we were mostly left alone by the obstetricians and we did feel that we were practitioners in our own right. We worked as a team, there were no medics bursting into rooms, no slavish adherence to labour ward protocols.

However, since moving to another area and beginning work in a large teaching hospital where the obstetricians are regarded almost as gods, I am working really simply to pay the bills – perhaps I’m `burnt out’ but I haven’t got much energy left.

Disillusionment? Yes.

Autonomy? No.
M

Guidelines not Protocols

Sara – I think you’ve asked a really tough question! I thought I’d figure this out shortly after qualifying but I’ve been practicing for two and a half years now and where I work the issue remains very dependent on the midwives and doctors surrounding me.

We have guidelines, which I fairly routinely ignore (e.g. no `routine’ CTG in active labour if it seems unnecessary), and the senior midwives by and large accept that we have flexible guidelines rather than protocols. However, few other midwives see any flexibility, and are intent on following guidelines. They have had many opportunities to contribute to the guidelines, so maybe it’s just that they agree with it all and I’m still new and haven’t had many chances to put forth other opinions.

The doctors are problematical in a positive way: the consultants are respectful of the midwife’s domain, but we seem to be expected to train up the SHOs in obstetrics … and I’m not always that confident on my obstetrics!!! There are no registrar level doctors. So it often feels as if we are making most of the decisions on a woman’s care – which is good I think, just intimidating if you’ve been in a teaching hospital with registrars etc. making many intermediate decisions.

Some days are good, and I am happy to provide the best care possible on labour ward in spite of other midwives walking past me to write in the notes that they have suggested interventions that I have not carried out (ARM, augmentation in second stage, etc.) …. then there are other days where I’m not sure I’m up to it. A senior midwife warned me that she would grab an emerging baby for me if I neglected to do a `hands on’ delivery rather than watch the birth with hands poised. So I will put my hands on if she is present. But then again, I will probably not call her to be a second midwife to a birth – having a second midwife is a guideline rather than a protocol. It all seems very fuzzy – this decisionmaking process – but I imagine that I am not alone in varying my practice to some degree to suit the situation.

Foremost in my mind is the mother/family and baby, and I’d personally risk a lot to do the best for them, but at times I’ve decided that means staying quiet so as to not disturb their faith in the health professionals around them. Doesn’t always feel good.

Last thought – because it doesn’t always feel safe to discuss different practice around some colleagues, I’ve found it important to keep in touch with like-minded midwives. I’m happy to talk with anyone of any opinion really, as there is a lot to learn from other more experienced midwives.

But at work I am reminded that the last open midwife member of the Association of Radical Midwives was forced out of her job. Or so the story goes…
Carol

Please Knock?

Are you able to say where you work now? Do obstetricians really burst into the room?

This makes me realise how lucky I am. What I am trying to figure out is whether those of us in London generally practise with less interference than those of us outside – which is what I am hearing anecdotally. Any opinions?

Where I work I think it is often a question of personality – there will always be a pushy new registrar who will try and stick their nose in but generally unless we ask for help we are left be.
Sara

Hovering in the Background

Dear Sara

Unfortunately yes they do walk into rooms unannounced when it has been decided that `it’ is a medical `case’ – otherwise they knock before coming in to say hello, we’re the doctors on call, just introducing ourselves. Recently I had a registrar outside the door who – because the woman was not progressing at the required 1 cm per hour (is there any evidence to support this?) was muttering synto, she needs synto, until her baby was born. He did refrain from interfering but only because I persuaded him that the FH was fine as was descent and effacement – afterwards it was, “I stand corrected sis – well done!”

Incidentally it is also required that VEs are written on the board (time, dilatation).

I’d rather not say where exactly I work, but it is outside London. Perhaps teaching hospitals/regional centres have a greater rate of intervention?
M

Midwives Training SHOs?

Forgive me for saying so, perhaps it is my naiveté, but what are midwives doing training SHOs in obstetrics? I can see that they should be training them in normal birth and midwifery (although I accept that not a lot of that happens in most consultant units) but surely the person who should be training the SHOs are the obstetricians – that is what I thought we paid them vast sums of money for!

Beverley

…er … yes!

Beverley – you’re right, of course, that consultant obstetricians ought to be training their juniors. In the everyday world of the maternity ward SHOs on their six month rotation in obstetrics are usually only used by midwives to site intravenous lines, get signed consent for planned caesarean sections and such. In large units, midwives would refer directly to a more experienced specialist doctor, i.e. the obstetric registrar, for most obstetric decision-making. The dilemma where I work is that the consultants are, thankfully, fairly non-interventive and, dare I say, absent unless called …. therefore when we want an obstetric opinion or by the Midwives Rules need to refer the case to the doctors the first point of contact is the SHO. This is out of politeness. In an urgent situation politeness disappears – the consultant is called directly – and we eventually inform the SHO and probably ask him/her to attend as an extra pair of hands.

But back to the everyday – I find myself wanting an obstetric opinion but needing to explain the situation to a doctor who is more or less knowledgable about obstetrics. Sometimes I don’t have a clue (raised liver enzyme levels but no other problem … medical referral needed?) and really need to push until I’m satisfied that the woman is getting adequate attention … other times the scene is anywhere between a teaching session and a near argument (e.g. shallow fetal heart decelerations with a raging fetal tachycardia ARE significant, get the consultant here to make a decision please, now!) All too often I find I cannot trust their decision making in situations where I am competent … so this makes me worry about those times when I am truly lost. I go home wondering why I should have to know obstetrics as well as my midwifery.

Another aspect of training the SHOs is introducing, to a few of them at least, the concept of informed choice and informed refusal. Treating women with respect, etc. No doubt this is discussed in medical school, but God help them if they simply act like other doctors! So there are some positive elements in our teaching role.

Both training up SHOs and advocating for women (against the system/protocols/doctor’s expectations, etc.) can seem like non-midwifery consumers of my energy at times. I’d rather be there for a family, concentrating on their needs in a simple way, rather than defending their slightly jaundiced baby against unnecessary blood tests or carefully documenting the care given in labour to reflect medio-legal issues and protocols (consent not given for ARM) rather than being completely honest about the decisionmaking (e.g. both mother and midwife feel that progress in labour is good and there is nothing much to be gained by an ARM). Even advocacy can be tiring. I can’t imagine much advocacy going on in a well-run birth centre! Support, communication, … but not that tinge of antagonism!
Carol

Autonomy? Not here

My recent experience is that it depends which shift and what staff you are working with. I have had staff and sister midwives walking into the room without even knocking, scanning notes quickly and telling me what the plan of action should be. Because we have a high induction rate, most of the women I care for are medically managed – I have little input other than to carry out the wishes of medical staff. Even when trying to give informed consent these women go with the medical plan. The unit has a `midwife led unit’ which more or less follows the protocols from labour ward.

I recently tried talking about some of these issues with other midwives – only to be told that women want this kind of care. I told them about my three student placements on a midwife led unit – discussing the lack of protocols – there was shock and disbelief from my colleagues. I said I hoped to work somewhere like this – a midwife told me I would need far more experience than I have (I’m eight months qualified and worked in labour ward all that time after the pre-reg course of three years) which I accept, but I feel that all I have ever experienced is obstetric management – I have normal birth theory, but little experience of it.

Some newly qualified midwives go straight into independent practice – so how much experience do you need to work in a community midwife led unit? If your training is supposed to qualify you to be an autonomous practitioner, why do you need two years experience to work in such a unit? Does this mean my training is basically flawed, that I’m not really a midwife? The midwives I work with obviously have a great deal of experience in hospital midwifery (obstetric nursing?) – they make me feel I know nothing – especially as they are nurse-midwives and I’m a direct entry midwife (this hospital only offers post-reg midwifery training). I defer to them, this makes me feel I let down the women I look after (does that make sense?). As I have so little experience of normal birth I sometimes feel I can’t back up what my gut feeling is about a certain case. Although I love this profession, and have women’s best interest at heart, I am not enjoying my practice – I am not autonomous, I have strict protocols to adhere to, the service is impersonal,
women are to be `delivered’ as soon as possible and transferred from labour ward within two hours (not easy if you want your woman to have skin-to-skin contact and time to breastfeed, before the tea and toast and shower).

I don’t feel I can do anything to change practice – even research doesn’t really help – because they only implement the research they like (sometimes you can make research say what you want it to say – like women don’t want a known midwife in labour, they don’t want continuity of care, they want PCAs for three days, to stay in hospital as long as possible after birth, large for dates policies are ok, all babes should have Vit K etc. etc.) Sorry to go on and on, I’ve had a particularly bad couple of months.

C

Keep Faith

Hang on in there! Well, perhaps not there, wherever it is, but hopefully somewhere else in the future. There must be hundreds (if not thousands) of us working in these awful places, I’m pulling out all the stops to change jobs but it is hard. This list, ARM, AIMS, have all given me the strength to carry on; for the last two years I’ve been going to work and getting through each shift telling myself that at least I’m reasonably solvent – but that’s no way to be a midwife really – I want to love the work again. I know what you mean about being pre-reg. – the general feeling seems to be that we’re just not up to scratch – no wonder when most of what we end up doing involves manipulating various machines!

Have faith in yourself & don’t let the b*****s get you down – you are a real midwife (who wants to be an obstetric nurse anyway?)
Max
If you want us, we want you

Here in Lymington we would (and have) happily appoint a newly qualified midwife. After all, that’s the point about being a midwife from the hour of registration! There are some advantages in this – you’re fresh, uncontaminated by labour ward fears and you’ll learn as you go with our support and encouragement. The prime factor in getting a job in such a unit is that you actually want to work in this setting and that counts for a great deal!

Lesley

Pretty Autonomous

In our unit we have two `midwifery’ wards for antenatal/postnatal care, which also includes delivery rooms for `low risk’ women. We also have a Main Delivery Unit (MDU) for women needing extra care in labour. On the wards, a woman can be admitted in labour, give birth, receive postnatal care and go home without any medical input. The midwives here are pretty autonomous. On MDU the situation is obviously more medicalised, but even so, I don’t think you get people bursting in unannounced. I can’t imagine having other midwives writing in `my’ notes….

My thoughts are that if you keep the senior midwife informed about how the woman is progressing, and you’re pretty clear on your rationale for her care, then they have no real reason for interfering. There’s usually a doctor around on MDU also, so keep them informed as well, emphasising that everything’s ok! We don’t usually have a second midwife at the birth, unless a problem is anticipated. (We’re not that well staffed!)

The name board on MDU is more or less just that, the woman’s name, parity, reason for being there (e.g. mec, ARM, epidural, previous c/s, etc) and midwife’s name. Midwives are rotated through the unit to gain experience in all areas by day and night.

The downside is that the wards are very busy, women in labour are sometimes left on their own for long periods, or have to be transferred to MDU because the delivery rooms are full. Often postnatal women feel neglected if the midwives are busy at a birth. If the unit is busy, we also suffer from the `unholy rush’ syndrome to get the women back to the ward.

I actually work as a community midwife, last year the community midwives were present at a third of all the area’s births. If I bring a woman in who needs to be on MDU (e.g. previous c/s, pph, grand multip, etc), I keep the senior midwife up to date on progress (out of courtesy), CMD (community midwife delivery) goes on the board, and I’m left to my own devices!

Don’t be worried about whether you’ve been a nurse or not, it’s not relevant. I agree with Lesley, once you’re qualified, you’re a midwife. It’s just experience, which we’re ALL developing ALL the time, and with support and encouragement from colleagues we will continue to grow.

Consultants are not gods, they’re just people like you and the women in your care, the more you deal with them, the more you will realise this. Talk through with your woman the plan of her care and the rationale for it, this will help to clarify it in your mind, enabling you to face up to unhelpful staff.

Sorry I’ve rambled on a bit. My unit is not perfect, but it seems better than others…
Janet

How to Keep Faith

Are you in a position to change your place of work to a hospital with less intervention, or a community team? I am also quite newly qualified in midwifery, and was beginning to lose my faith in the birthing process, as I work in a highly medicalised unit. After just a few months, having been very comfortable about homebirth (I attended two as a student midwife), I began to think that women must be nuts to want a homebirth!! You see so many `dramas’, women rushed into theatre with a `brady’ which doesn’t recover etc. I decided to go and work with an independent midwife for a week – the best thing I have ever done!

I personally do not believe that as a midwife you need a prescribed amount of time in a hospital setting before moving to the community, as long as the team is willing to support you in your learning.

Do not let these midwives where you work make you feel that you know nothing! As someone who questions, you are already streets ahead. They may feel threatened when you wish to discuss certain issues because they have lost sight of the rationale for care (or lack of it). They believe that management of labour, and the use of technology is generally for the best for women and their babies. They believe in the system and care they provide and don’t like it being challenged, especially by someone who is newly qualified and has limited experience and knowledge (in their eyes), particularly with respect to specific hospital protocol.

Keep your knowledge and belief in keeping birth normal close to your heart. Use this, and contact with other midwives/women who feel the same way, to draw strength from. Be quietly confident in what you believe, and know that the women that you look after (despite difficult protocols) are the lucky ones. Think about spending some time with a local independent midwife or birth centre. My midwifery spirit is currently making contact with ozone!!

(Or maybe I’m manic….?!!) I know where I am going, have re-gained my faith in normal (physiological) birth, and therefore practice with increased confidence and autonomy.

Good luck, and remember, WOMEN NEED YOU!!
Karen

AH updated 12 November 2000